RE: Was told by Cigna there was an exclusion, found out later it is covered

[Guest guest]

Good research, here. Insurance companies don't expect us to dig deep -- they also don't expect us to appeal more than one time. 90% of people don't even appeal when they are told they have been denied coverage. That's why it's important to find a wiggle space, even if there is an exclusion.Of course, there will be times when the number of appeals, no matter how well crafted may not be accepted, but the more ammunition we have to work with, the better. Thanks for posting this information for those who have CIGNA. mom to Quinn 11/99, DOCband grad 10/00>------- Original Message ------->From : holdenhl[mailto:holdenhl@...]>Sent : 3/26/2008 3:32:13 PM>To : Plagiocephaly >Cc : >Subject : RE: Was told by Cigna there was an exclusion, found out la

ter it is covered>>sorry this is a fairly long post but I'm hoping it may help someone in the future. I will number the information in the order that I found it out:1.Cranial Tech called to tell me that they called Cigna and they don'tcover the DOC band because of an exclusion in the policy. I think that I need to contact Cigna myself to see what that exclusion is, like whether it is considered "not medically neccesary" I need the specific wording. I read something on Cigna's website called a "Coverage Position" that specifically talks about coverage for cranial orhtotic devices, but it does say that some Cigna plans may specifically exclude or limit coverage. 2.I called Cigna yesterday and spoke to a Rep. that was nice. I asked her if my plan covers a cranial orthotic device. she asked what that was and I explained it. At first she couldn't find anything then I asked her to look under durable medi

cal equipment and still nothing, then I asked her to look under External Prosthetic Apliance and Devices and she found the exclusion there! I asked her if she could fax me what she saw and she said she could have a letter written up for me explaining that and it would be faxed that afternoon or the next day. I just received the fax. I can't scan it here at work but I can type what it says:On March 25, 2008 you called to inquire on your plan benefits. This benefit was for External Prosthetic Appliance [EPA]. After reviewing your benefits it has been determined that the EAP you were inquiring on is listed in your exclusion of benefits.EAP exclusions under your plan are as followsExcludes the following orhoses & orthotic devices: prefabricated foot orthoses; cranial banding/cranial orthoses/other similar devices except when used postoperatively for synostic plagiocephaly; and moderate to severe nonsynostoti

c positional plagiocepahly as medically necessary: ext.3.After reading the exclusion again I read it as saying:excludes cranial banding except when used for moderate to severe nonsynostoic positional plagiocephaly as medically necessary. This to me means that if the doctor sends the note of medical neccessity and meets the conditions then there is coverage. I read the "coverage position"(found on Cigna's website) as saying: Coverage for cranial orthotic devices is generally subject to the terms, conditions and limitations of the External Prosthetic Appliance and Devices benefit.If coverage for a cranial orthotic device is available, the following conditions of coverage apply.Cigna covers a cranial orhtotic device as medicall necessary for the treatment of either of the following conditions:􀂾 synostotic plagiocephaly following surgical correction􀂾 moderate to severe non

synostotic positional plagiocephaly when ALL of the following conditions are met:􀂾 There is photographic evidence supporting moderate to severe nonsynostotic positionalplagiocephaly.􀂾 The child is EITHER ONE of the following:o between three and five months of age and has failed to respond to a two-monthtrial of repositioning therapyo age six months to 18 months of age􀂾 There is documentation of EITHER of the following criteria:o cephalic index ± at least two standard deviations from the mean for theappropriate gender/age (see Table 1)o asymmetry of 12 mm or more in ONE of the following measures:􀂃 cranial vault􀂃 skull base􀂃 orbitotragial depth (see Table 2) meets this criteria. I just got back from meeting with a nurse in our company (we have nurse advocates here) and she said this means we are covered and that cranial tech should be sending the doctor's let

ter and prescription to Cigna and it should be covered. She is going to take my info and contact her Cigna rep to get them talking to cranial tech and she also said "Good Job". ------------------------------------For more plagio info